Long-term outcomes in Chinese patients with chronic hepatitis B receiving nucleoside/nucleotide analogue therapy in real-world clinical practice: 5-year results from the EVOLVE study

BACKGROUND

In China, the optimal management of individuals living with chronic HBV infection (CHB) remains an unmet need. The EVOLVE Study was a 5-year prospective, longitudinal, observational study that compared the clinical outcomes in treatment-naive CHB patients receiving entecavir (ETV) or lamivudine (LAM)-based therapies.

METHODS

Males or females aged ≥18 years, diagnosed with CHB regardless of cirrhosis or hepatitis B e antigen (HBeAg) status were enrolled from tier 2 city hospitals (between 2012-2014). The choice of initial therapy and subsequent treatment modifications was at the discretion of treating physicians. Key outcomes included treatment modifications, virological response (HBV DNA <300 copies/ml) and HBV disease progression.

RESULTS

Of the 3,408 patients enrolled, 1,807 and 628 received ETV and LAM-based therapy, respectively. The mean age was 39.5 years, 74% were male and 22.9% had cirrhosis. The rate of treatment modification was higher in the LAM-based versus ETV group (25.9% versus 13.7%); viral breakthrough was the most common reason in the LAM-based group versus financial reasons in the ETV group. At week 240, the virological response rate was 73% in both treatment groups. Compared with LAM-based therapy, ETV was associated with a significantly lower incidence of viral breakthrough (12.6% versus 2.1%) and genotypic resistance (10.1% versus 1.2%; P<0.0001 for both); significantly lower risk of HBV disease progression (14.0% versus 10.7%; P=0.0113); and lower rates of progression to decompensated cirrhosis (9.6% versus 6.4%) and hepatocellular carcinoma (1.9% versus 0.8%).

CONCLUSIONS

This real-world, longitudinal study demonstrated a significantly lower risk of HBV-related disease progression, viral breakthrough and resistance with ETV versus LAM-based therapy. ClinicalTrials.gov NCT01726439.

Risk of hepatitis B surface antigen seroreversion after corticosteroid treatment in patients with previous hepatitis B virus exposure

BACKGROUND & AIMS

Systemic corticosteroids may cause HBV reactivation, but the impact on patients with previous HBV exposure is poorly defined. We aimed to study the risk of HBsAg seroreversion and hepatitis flare in patients with previous HBV exposure.

METHODS

Patients who were negative for HBsAg and received corticosteroids between 2001-2010 were included. Patients who were positive for antibody to HBsAg (anti-HBs) and/or to HBcAg (anti-HBc) were defined as having previous HBV exposure. The primary endpoint was HBsAg seroreversion; the secondary endpoint was hepatitis flare (alanine aminotransferase >80 U/L) at 1 year.

RESULTS

A total of 12,997 patients fulfilled the inclusion criteria: anti-HBs positive only (n = 10,561); anti-HBc positive only (n = 970); anti-HBs & anti-HBc positive (n = 830) and anti-HBs & anti-HBc negative (n = 636). HBsAg seroreversion occurred in 165 patients. Patients who were anti-HBc positive only had a higher risk of HBsAg seroreversion (1-year incidence 1.8%) than those negative for both anti-HBs & anti-HBc (0%; p = 0.014). Patients with previous HBV exposure had a similarly low risk of liver failure as unexposed individuals (1.1% vs. 0.9%). The risk of a hepatitis flare started to increase in those receiving corticosteroids at peak daily doses of 20-40 mg (adjusted hazard ratio [HR] 2.19, p = 0.048) or >40 mg (aHR 2.11, p = 0.015) prednisolone equivalents for <7 days, and was increased at treatment durations of 7-28 days and >28 days (aHR 2.02-3.85; p <0.001-0.012).

CONCLUSIONS

In HBsAg-negative patients who were only anti-HBc positive, high peak daily doses of corticosteroids increased the risk of hepatitis flare, but not seroreversion. The rate of liver failure was low and similar in HBV exposed and unexposed individuals; there were no deaths, nor any requirement for liver transplantation.

LAY SUMMARY

It is important to know the hepatitis B virus (HBV) status before starting corticosteroid therapy. Patients with resolved HBV infection without detectable immunity are at an increased risk of HBV surface antigen seroreversion after corticosteroid therapy. High peak daily doses of corticosteroids (>40 mg prednisolone equivalents) increase the risk of hepatitis flare, but not seroreversion, in patients with previous exposure to HBV, irrespective of the duration of treatment. Interval monitoring of liver biochemistries is essential for the early detection of hepatitis flares in these patients.

Non-invasive assessment of hepatic fibrosis: comparison of MR elastography to transient elastography and intravoxel incoherent motion diffusion-weighted MRI

OBJECTIVE

To compare the ability of MR elastography (MRE) with transient elastography (TE) and intravoxel incoherent motion (IVIM) diffusion-weighted MRI in staging hepatic fibrosis (HF).

MATERIALS AND METHODS

100 patients with chronic liver disease and 25 healthy volunteers underwent preoperative MRE, IVIM on a 3T MRI unit, and ultrasound-based TE. Liver stiffness measurement from MRE (LSM-MRE) and liver stiffness measurement from TE (LSM-TE) were measured; four diffusion parameters including the true diffusion coefficient (D_t), pseudo-diffusion coefficient, perfusion fraction (f), and apparent diffusion coefficient (ADC) were calculated. Receiver operating characteristic (ROC) curves were performed for significant parameters to compare the diagnosis performance for detecting HF.

RESULTS

LSM-MRE and LSM-TE values showed positive correlation with the fibrosis stage (r = 0.910 and 0.813, P < 0.001). D_t, f, and ADC values showed negative correlation with the fibrosis stage (r = - 0.727, - 0.503, and - 0.601, all P < 0.001). The area under the ROC curve (AUC) of LSM-MRE (AUC = 0.965, 0.957, 0.983) was significantly higher than that of LSM-TE (AUC = 0.906, 0.913, 0.931) and D_t (AUC = 0.875, 0.879, 0.861) in discriminating significant HF (≥ F2), advanced HF (≥ F3), or cirrhosis (F4) (all P < 0.05). Although LSM-TE showed higher AUCs than D_t in detecting fibrosis stages, there were no significant differences between LSM-TE and D_t (P > 0.05) except for detecting F4 (P < 0.05).

CONCLUSION

MRE shows excellent diagnostic performance for predicting significant fibrosis, advanced fibrosis compared with TE and IVIM, while TE and IVIM have comparable diagnostic performance.

Progress towards elimination goals for viral hepatitis

The global burden of viral hepatitis is substantial; in terms of mortality, hepatitis B virus and hepatitis C virus infections are on a par with HIV, malaria and tuberculosis, among the top four global infectious diseases. In 2016, the 194 Member States of the World Health Organization committed to eliminating viral hepatitis as a public health threat by 2030, with a particular focus on hepatitis B virus and hepatitis C virus infection. With only 10 years to go until the 2030 deadline is reached, and although much progress has been made towards elimination, there are still some important gaps in terms of policy and progress. In this Viewpoint, we asked a selection of scientists and clinicians working in the viral hepatitis field for their opinions on whether elimination of viral hepatitis by 2030 is feasible, what the key areas of progress are and what the focus for the next 10 years and beyond should be for viral hepatitis elimination.

Strategies to eliminate HBV infection: an update

Chronic hepatitis B (CHB) is a widespread global infection and a leading cause of hepatocellular carcinoma and liver failure. Current approaches to treat CHB involve the suppression of viral replication with either interferon or nucleos(t)ide analog therapy, but neither of these approaches can reliably induce viral eradication, immunologic control or long-lived viral suppression in the absence of continued therapy. In this update, we explore the major obstacles of CHB cure and review new therapeutic strategies and drug candidates.

Safety and efficacy of immune checkpoint inhibitors in patients with HBV/HCV infection and advanced-stage cancer: A systematic review

BACKGROUND

Cancer patients with hepatitis B or C virus (HBV/HCV) infection are commonly seen in clinical practice, however, the data of safety and efficacy of immune checkpoint inhibitors (ICIs) among them are sparse, because active HBV/HCV infected patients were generally excluded by clinical trials and the correlation between previous infection and treatment-related adverse events was rarely reported. This review is the first to summarize the results on the safety and efficacy of immune checkpoint inhibitors (ICIs) in HBV/HCV infected cancer patients.

METHOD

We searched literature and conference abstracts in PubMed and Embase followed the PRISMA guideline, using the keywords hepatitis B, hepatitis C, immune checkpoint inhibitor, ipilimumab, nivolumab, pembrolizumab, atezolizumab, durvalumab, avelumab, tremelimumab. Studies described patients with HBV/HCV infection treated with ICIs for advanced stage cancer were included.

FINDINGS

One hundred eighty six patients were identified from 14 articles (8 case reports, 4 case series, 2 trials). Eighty nine patients had HBV infection and 98 had HCV infection (1 both had HBV and HCV). The majority of patients were treated with PD-1 inhibitor monotherapy (140 of 186, 75.3%) and anti-CTLA-4 monotherapy (36 of 186, 19.4%). No treatment-related death was reported. The incidence of grade 3 or 4 hepatic transaminase elevating (HTE) in HBV and HCV infected patients were 3.4% (3/89) and 17.3% (17/98), respectively. 2.8% patients without antivirus therapy experienced virus load increasing, and 1.9% presented virus-related hepatitis. In terms of efficacy, 22 of 118 (18.6%) patients with liver cancer, 11 of 34 (32.4%) with melanoma, 1 of 6 (16.7%) with NSCLC showed objective responses (CR and PR) to ICIs in spite of lines of therapies.

CONCLUSION

ICIs is considered to be safe and effective in advanced cancer patients with hepatitis B or C infection, but still has possibilities to reactive hepatitis virus due to uncertain mechanisms. We recommend that those with viral hepatitis be monitored closely and treated with antiviral therapy if indicated before or during ICIs treatment.

Hepatitis B and C virus infection and risk of haematological malignancies

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are classified as oncogenic human viruses. Chronic HBV and HCV infections are associated with higher risk of haematological malignancy development. Direct and indirect oncogenic mechanisms have been demonstrated for both HBV and HCV in several studies. HCV and overt/occult HBV infections in patients with oncohaematological disease constitute an impediment and a threat during immunosuppressive chemotherapy treatment. We review the HBV and HCV oncogenic mechanisms and the impact and the safety of antiviral treatment in patients with haematological malignancies.

An expert review on the use of tenofovir alafenamide for the treatment of chronic hepatitis B virus infection in Asia

Asia has intermediate-to-high prevalence and high morbidity of hepatitis B virus (HBV) infection. The use of guideline-recommended nucleos(t)ide analogs with high barrier to resistance, such as entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF), is one of the key interventions for curbing HBV infection and associated morbidity in Asia. However, there are some challenges to the use of ETV and TDF; while ETV is associated with high resistance in lamivudine (LAM)-exposed (especially LAM-refractory) patients; bone and renal safety issues are a major concern with TDF. Hence, a panel of twenty-eight expert hepatologists from Asia convened, reviewed the literature, and developed the current expert opinion-based review article for the use of TAF in the resource-constrained settings in Asia. This article provides a comprehensive review of two large, phase 3, double-blind, randomized controlled trials of TAF versus TDF in HBeAg-negative (study 0108) and HBeAg-positive (study 0110) chronic HBV patients (> 70% Asians). These studies revealed as follows: (1) non-inferiority for the proportion of patients who had HBV DNA < 29 IU/mL; (2) significantly high rate of normalization of alanine aminotransferase levels; (3) no incidence of resistance; and (4) significantly better bone and renal safety, with TAF vs. TDF up to 144 weeks. Considering the benefits of TAF, the expert panel proposed recommendations for optimizing the use of TAF in Asia, along with guidance on specific patient groups at risk of renal or bone disease suitable for TAF therapy. The guidance provided in this article may help clinicians optimize the use of TAF in Asia.

Addressing the global burden of hepatitis B virus while developing long-acting injectables for the prevention and treatment of HIV

The first long-acting formulations of HIV drugs are undergoing regulatory review for use in maintenance of viral suppression in people with HIV. Although these novel drug formulations could contribute greatly to HIV treatment and prevention efforts, their lack of activity against hepatitis B virus (HBV) could limit their global impact, particularly in populations with high burdens of both HIV and HBV. An urgent need for greater investment in research and development of long-acting drugs with dual activity against HIV and HBV exists. Access to long-acting HIV drug formulations with dual activity against HBV would be transformative and have a great impact on efforts to prevent, treat, and eradicate both of these important global epidemics.

Risk of Hepatocellular Carcinoma in Patients Treated With Entecavir vs Tenofovir for Chronic Hepatitis B: A Korean Nationwide Cohort Study

Importance

Entecavir and tenofovir disoproxil fumarate have comparable efficacy in achieving surrogate end points, including virologic response, and are equally recommended as first-line treatments for patients with chronic hepatitis B (CHB). However, it is unclear whether treatment with these drugs is associated with equivalent clinical outcomes, especially development of hepatocellular carcinoma (HCC).

Objective

To compare entecavir and tenofovir in terms of the risk of HCC and death or liver transplant in patients with CHB infection.

Design, Setting, and Participants

A nationwide historical population cohort study involving treatment-naive adult patients with CHB who started treatment with entecavir (n = 11 464) or tenofovir disoproxil fumarate (n = 12 692) between January 1, 2012, and December 31, 2014, using data from the Korean National Health Insurance Service database. As validation, a hospital cohort of patients with CHB treated with entecavir (n = 1560) or tenofovir (n = 1141) in a tertiary referral center between January 1, 2010, and December 31, 2016, were analyzed. Nationwide cohort data were retrieved from January 1, 2010, to December 31, 2016, and hospital cohort data from January 1, 2010, to October 31, 2017.

Main Outcomes and Measures

Cumulative incidence rates of HCC and death and transplant rates.

Results

Among the population cohort of 24 156, the mean (SD) age was 48.9 (9.8) years, and 15 120 patients (62.6%) were male. Among the hospital cohort of 2701, the mean (SD) age was 48.8 (10.5) years and 1657 patients (61.3%) were male. In the population cohort, the annual incidence rate of HCC was significantly lower in the tenofovir group (0.64 per 100 person-years [PY]) than in the entecavir group (1.06 per 100 PY). By multivariable-adjusted analysis, tenofovir therapy was associated with a significantly lower risk of HCC (hazard ratio [HR], 0.61; 95% CI, 0.54-0.70) and all-cause mortality or transplant (HR, 0.77; 95% CI, 0.65-0.92) compared with entecavir. The tenofovir group also showed a significantly lower risk of HCC in the 10 923-pair propensity score-matched population cohort (HR, 0.62; 95% CI, 0.54-0.70) and 869-pair propensity score-matched hospital cohort (HR, 0.68; 95% CI, 0.46-0.99) compared with the entecavir group.

Conclusions and Relevance

This study suggests that tenofovir treatment was associated with a significantly lower risk of HCC compared with entecavir treatment in a population-based cohort of adults with CHB; these findings were validated in a hospital cohort. Given the poor prognosis of patients with HCC, these findings may have considerable clinical implications in prevention of this cancer in patients with CHB infection.

Role of the genetic variant CCR5Δ32 in HBV infection and HBV/HIV co-infection

CCR5 is a chemokine receptor that mediates the action of inflammatory cells, besides acting as an HIV co-receptor. CCR5Δ32 states for a genetic variant containing a 32 base pair deletion in the coding region of the CCR5 gene. In homozygosis, CCR5Δ32 results in the lack of CCR5 expression on the cell surface, which was associated with protection against HIV infection. Heterozygous individuals for CCR5Δ32 have a reduced CCR5 expression. Recent evidence demonstrates that CCR5 and CCR5Δ32 are involved in the pathogenesis of other viral infections besides HIV infection. Nevertheless, the role of CCR5 and CCR5Δ32 in HBV infection is not clear and conflicting results have been reported. Thus, the objective of this study was to investigate the role of CCR5Δ32 in HBV mono-infection and HBV/HIV co-infection in a population from southern Brazil. A total of 1113 individuals were evaluated, divided in controls (n = 334), HBV+ (n = 335), HBV+/HIV+ (n = 144), and including an HIV+ group to complement the analyses (n = 300, obtained from a previous study of our research team). The CCR5Δ32 allele frequencies found were 7.5 %, 9.0 %, and 3.1 %, respectively for controls, HBV+, and HBV+/HIV+ patients. The individuals were classified in CCR5Δ32 allele carriers and CCR5Δ32 allele non-carriers and the groups were compared using binary logistic regression adjusted for covariates. No significant effect of the CCR5Δ32 variant was observed on the susceptibility or protection against HBV mono-infection in individuals from southern Brazil. A potential protective effect of CCR5Δ32 on HBV/HIV co-infection was observed. However, it can be due to the effect of CCR5Δ32 in the protection against HIV infection or external factors not covered in the study. Finally, this study contributes to the understanding of the role of CCR5 in HBV infection, suggesting no effect of CCR5Δ32 on susceptibility to HBV mono-infection.

Kinetics of hepatitis B surface antigen quasispecies during REP 2139-Ca therapy in HBeAg-positive chronic HBV infection

Chronic HBV infection results in various clinical manifestations due to different levels of immune response. In recent years, hepatitis B treatment has improved by long-term administration of nucleos(t)ide analogues (NUCs) and peg-interferon. Nucleic acid polymers (NAPs; REP 2139-Ca and REP 2139-Mg) are new antiviral drugs that block the assembly of subviral particles, thus preventing the release of HBsAg and allowing its clearance and restoration of functional control of infection when combined with various immunotherapies. In the REP 102 study (NCT02646189), 9 of 12 patients showed substantial reduction of HBsAg and seroconversion to anti-HBs in response to REP 2139-Ca, whereas 3 of 12 patients did not show responses (>1 log reduction of HBsAg and HBV DNA from baseline). We characterized the dynamic changes of HBV quasispecies (QS) within the major hydrophilic region (MHR) of the 'pre-S/S' open reading frame including the 'a' determinant in responders and nonresponders of the REP 102 study and four untreated matched controls. HBV QS complexity at baseline varied slightly between responders and nonresponders (P = .28). However, these responders showed significant decline in viral complexity (P = .001) as REP 2139-Ca therapy progressed but no significant change in complexity was observed among the nonresponders (P = .99). The MHR mutations were more frequently observed in responders than in nonresponders and matched controls. No mutations were observed in 'a' determinant of major QS population which may interfere with the detection of HBsAg by diagnostic assays. No specific mutations were found within the MHR which could explain patients' poor HBsAg response during REP 2139-Ca therapy.

Enhancing the value of women’s reproductive rights through community based interventions in upper Egypt governorates: a randomized interventional study

Background

In 2012, the WHO described the quality of health care as the route to equity and dignity for women and children.

Aim of the work

To provide community based support and empowerment to women in childbearing period to seek optimal prenatal, natal and postnatal healthcare. Achieving this is anticipated to decrease maternal morbidity and mortality in Egypt.

Subjects and methods

An interventional study was conducted among women in childbearing period in the poorest two governorates of Upper Egypt. The study passed through three stages over three and a half years; pre-interventional assessment of awareness (n = 1000), educational interventions targeting the health providers and all women in childbearing period in their communities (n = 20,494), and post-intervention evaluation of change in awareness of their rights for prenatal, natal and postnatal care (no = 1150).

Results

The studied indicators relating to receiving care in pregnancy, labor, and puerperium have changed dramatically as a result of the study interventions. Results of the study showed that before interventions, the surveyed women had inaccurate knowledge regarding most of the items related to their rights. The percentages of women aware of their right to have pregnancy card increased and those who possessed a pregnancy card were doubled with a significant percent change of more than 25%. Some indicators showed more than 75% improvement, including; percent of surveyed women who knew that it’s their right to follow up their pregnancy and to deliver with a specialized doctor, a trained nurse or at an equipped health facility, and those who knew their right to have at least two home preparations necessary for safe delivery at home.

Conclusion and recommendations

More work is needed in order to achieve the targeted reduction of maternal mortality. This could be achieved by ensuring accessible and high quality care provided by the governmental health facilities together with increasing the awareness of women regarding their rights in receiving such care.

Chronic inflammation: key player and biomarker-set to predict and prevent cancer development and progression based on individualized patient profiles

A strong relationship exists between tumor and inflammation, which is the hot point in cancer research. Inflammation can promote the occurrence and development of cancer by promoting blood vessel growth, cancer cell proliferation, and tumor invasiveness, negatively regulating immune response, and changing the efficacy of certain anti-tumor drugs. It has been demonstrated that there are a large number of inflammatory factors and inflammatory cells in the tumor microenvironment, and tumor-promoting immunity and anti-tumor immunity exist simultaneously in the tumor microenvironment. The typical relationship between chronic inflammation and tumor has been presented by the relationships between Helicobacter pylori, chronic gastritis, and gastric cancer; between smoking, development of chronic pneumonia, and lung cancer; and between hepatitis virus (mainly hepatitis virus B and C), development of chronic hepatitis, and liver cancer. The prevention of chronic inflammation is a factor that can prevent cancer, so it effectively inhibits or blocks the occurrence, development, and progression of the chronic inflammation process playing important roles in the prevention of cancer. Monitoring of the causes and inflammatory factors in chronic inflammation processes is a useful way to predict cancer and assess the efficiency of cancer prevention. Chronic inflammation-based biomarkers are useful tools to predict and prevent cancer.

Effect of Statin Use on Liver Cancer Mortality Considering Hypercholesterolemia and Obesity in Patients with Non-Cirrhotic Chronic Hepatitis B

Little is known about the benefits of statin use on liver cancer mortality among patients with chronic hepatitis B (CHB) considering hypercholesterolemia and obesity. A nationwide retrospective cohort study was conducted using data from a Health Examination Cohort of the National Health Insurance Service of Korea. Data on CHB patients with no other concurrent liver disease were acquired, and statin use was defined as a cumulative daily dose ≥28. A 3-year landmark analysis was performed to avoid immortal time bias. Patients who started statin therapy within the landmark date were considered statin users. A Cox regression analysis was applied to assess associations between statin use and liver cancer mortality considering hypercholesterolemia and obesity. Among 13063 patients, 193 (1.5%) died of liver cancer during the mean follow-up period of 10.6 years. After adjusting for demographic and metabolic factors, statin use [hazard ratio (HR), 0.17; 95% confidence interval (CI), 0.04-0.70] and hypercholesterolemia (HR, 0.46; 95% CI, 0.24-0.88 for total cholesterol ≥240 mg/dL) were associated with a decreased risk of liver cancer mortality, whereas body mass index (BMI) ≥30 kg/m² was associated with an increased risk of liver cancer mortality (HR, 2.46; 95% CI, 1.20-5.06). This study showed that statin use was associated with decreased liver cancer mortality when adjusting for cholesterol levels and BMI. This study found that hypercholesterolemia was independently associated with decreased liver cancer mortality regardless of statin use.

Quantitative examination of the inhibitory activation of molecular targeting agents in hepatocellular carcinoma patient-derived cell invasion via a novel in vivo tumor model

BACKGROUND

The outcomes for patients with advanced hepatocellular carcinoma (HCC) receiving sorafenib are far from satisfactory because of treatment resistance to sorafenib. However, the exact mechanism of resistance to sorafenib remains unclear and it is valuable to establish a novel mouse model to quantitatively analyze the inhibition rates of sorafenib on the invasive growth of HCC cells in the liver.

METHODS

HCC tissue microblocks derived from patients were cultured and mixed with hydrogel drops. Then, hydrogel drops containing microblocks of HCC tissue were attached onto the surface of the livers of nude mice to form lesions or nodules of HCC. The mice received molecular targeting agents through oral administration. Livers with tumor nodules were harvested for H&E staining (hematoxylin-eosin staining) analysis and H&E staining images were quantitatively analyzed using image J software. The invasive growth of HCC cells into the liver was calculated using the depth of the lesions compared with the total thickness of the liver.

RESULTS

Microblocks containing cells derived from HCC patients can form lesions in the liver of nude mice. Oral administration of molecular targeting agents inhibited the invasive growth of HCC cells in the liver of nude mice.

CONCLUSIONS

The model established in this study involves the invasive growth of HCC cells in the liver of nude mice, and the model allows for the quantitative analysis of the inhibitory effect of molecular targeting agents on the invasion of HCC cells in vivo.

Hepatitis B Virus Infection: Overview

Hepatitis B virus (HBV) is a DNA virus, belonging to the Hepadnaviridae family. It is a partially double-stranded DNA virus with a small viral genome (3.2 kb). Chronic HBV infection remains a global public health problem. If left untreated, chronic HBV infection can progress to end-stage liver disease, such as liver cirrhosis and hepatocellular carcinoma (HCC). In recent years, tremendous advances in the field of HBV basic and clinical research have been achieved, ranging from the HBV biological characteristics, immunopathogenesis, and animal models to the development of new therapeutic strategies and new drugs against HBV. In this overview, we begin with a brief history of HBV discovery and treatment milestones. We then briefly summarize the HBV research advances, which will be detailed in the following chapters.

Patients Lost after Anti-HCV-Positive Finding in a Tertiary Care University Hospital: Increased Awareness and Action is Necessary to Eradicate HCV

OBJECTIVES

Though there is a global effort to eradicate hepatitis C infection (HCV), several obstacles remain. Many patients infected with the virus are not detected or go untreated. The goal of this study was to identify any barriers to treatment and any difficulties contributing to the elimination of HCV infection at a tertiary care university hospital.

METHODS

This was a retrospective review. The hospital data system was searched for records of patients admitted to the hospital for any reason from between 2013 and 2018 who were screened for viral markers and determined to be anti-HCV positive. The follow-up performed was then analyzed.

RESULTS

Viral marker testing was requested for 65,853 patients during the study period. Of those, 64.735 (98.3%) were found to be anti-HCV negative and 1118 (1.7%) were anti-HCV positive. In all, 392 (35.06%) were detected in the gastroenterology department, 417 (37.3%) were patients in the infectious diseases department, and 309 (27.64%) were identified in other clinics, including emergency services, the blood bank, and others. There were 30/392 (7.65%) patients admitted to the gastroenterology clinic who declined a biopsy and/or treatment. In other clinics, 88/309 (28.5%) patients were identified who were not treated for HCV and not followed up because they were not referred to the related specialty department.

CONCLUSION

It was determined that there was a significant gap in referring patients to the appropriate specialized department following an anti-HCV positive finding and thus to appropriate follow-up and treatment programs.

Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt

BACKGROUND

Hepatitis B virus (HBV) infection is the most common serious liver infection. The study aimed to evaluate the effect of a HBV protection intervention on interns, as regards their knowledge, attitude and immune response to HB vaccine and to identify the factors affecting their compliance and immune response to HB vaccination at Zagazig University Hospitals.

METHODS

A quasi-experimental study was conducted in 3 phases over 10 months. Phase 1: assessment of knowledge, attitude and HCV/HBV immune status. Phase 2: the implementation of HBV protection campaign; vaccine administration and health education sessions. Phase 3: the assessment of the immune response to the vaccine and the change in knowledge and attitude.

RESULTS

Out of 120 participants, 60% were compliant to the vaccination schedule. Needle-stick injury, the seriousness of HBV infection and attendance of infection control courses are the motivating factors to vaccination (p < 0.05). After the 3rd dose, 9.7% were non-responders. BMI and diabetes were the statistically significant predictors of the immune response. The HCWs compliant with vaccination schedule had higher mean scores regarding; total knowledge (15.5 ± 2.1), p < 0.0001 and attitude (14.34 ± 3.8) p < 0.05. A significant improvement is recorded from the posttest results, p < 0.000.

CONCLUSIONS

A comprehensive protective program against HBV is an effective tool. A compulsory vaccination program is still needed for interns. Post vaccination monitoring program, including protective measures for vaccine non responders is urgently needed with strict follow up of at risk groups. Occult HBV cases should not be overlooked when screening for immune response to vaccine.

Use of HBsAg quantification in the natural history and treatment of chronic hepatitis B

In patients with chronic hepatitis B (CHB) infection, it is important to monitor the natural history, assess treatment response, and predict the risk of liver-related complications. Quantification of serum hepatitis B surface antigen (HBsAg) has gained wide interests since the last decade. It is secreted from hepatocytes in both hepatitis B e antigen (HBeAg)-positive and HBeAg-negative phases of the disease, and can be transcribed and translated from different sources of viral genome [ccc DNA or integrated hepatitis B virus (HBV) DNA]. In untreated patients, it declines slowly through the natural course and remains stable for a long time after HBeAg seroconversion. In patients treated with nucleos(t)ide analogues (NA), it also declines very slowly, even though serum hepatitis B DNA has been rendered negative. Low serum HBsAg may predict either spontaneous or treatment-induced HBsAg seroclearance, and potentially selects out HBeAg-negative patients who can safely stop NA. High serum HBsAg is associated with high risk of hepatocellular carcinoma in untreated population, and predicts treatment failure in patients receiving pegylated interferon. These potential roles of HBsAg quantification are applicable to selected populations only. There is also a need for novel markers to study the effect of emerging antiviral therapies targeting various parts of the HBV cycle to reflect their distinct mechanistic effects. Several agents measuring HBsAg levels have shown rapid and significant decline. Ongoing studies are required to demonstrate the sustainability of HBsAg suppression by these novel agents.

Occult hepatitis B infection by a recombinant D/C virus in an immunosuppressed patient

Approximately 300 million people worldwide were living with chronic hepatitis B virus infection as of 2016, however, this number does not account for those who might be living with occult hepatitis B virus infection due to difficulty diagnosing this condition. The multiple genotypes and the ability of the hepatitis B virus to acquire mutations that down-regulate its expression make occult hepatitis B virus infection a very elusive diagnosis. This is especially worrisome when there is a need to start immunosuppressive therapies, since there is a risk of reactivation in undiagnosed patients. We present a case of female patient who was referred to the consultation because she was about to start chemotherapy with an anti-CD20 agent and had a positive anti-HBc and anti-HBs. During routine workup an occult hepatitis B virus infection was diagnosed. Upon further study mutations in the PreCore and Basal Core Promoter regions were identified, as well as, a double genotype D/C. Therapy with tenofovir was initiated before the patient was started on chemotherapy. This case highlights the importance of comprehensive studying of patients who present with apparently resolved chronic hepatitis B virus infection, especially when they are about to start immunosuppressive therapies.

Trends in the prevalence of chronic liver disease in the Korean adult population, 1998-2017

Data on the trends in the prevalence of chronic liver disease (CLD) in Korea are scarce. This study aimed to evaluate whether the CLD prevalence changed between 1998-2001 and 2016-2017. Data were extracted from the Korea National Health and Nutrition Examination Survey (1998-2001 to 2016-2017; n=25,893). Non-alcoholic fatty liver disease (NAFLD) was defined as a hepatic steatosis index >36 in the absence of any other evidence of CLD. The definition of alcoholrelated liver disease (ALD) was excessive alcohol consumption (≥210 g/week for men and ≥140 g/week for women) and an ALD/NAFLD index >0. The prevalence of NAFLD increased from 18.6% (95% confidence interval [CI], 17.8-19.5%) in 1998-2001 to 21.5% (95% CI, 20.6-22.6%) in 2016-2017. During the same time period, increases were observed in the prevalence of obesity (27.0 vs. 35.1%), central obesity (29.4 vs. 36.0%), diabetes (7.5 vs. 10.6%), and excessive drinking (7.3 vs. 10.5%). ALD prevalence also increased from 3.8% (95% CI, 3.4-4.2%) to 7.0% (95% CI, 6.4-7.6%). In contrast, chronic hepatitis B decreased from 5.1% (95% CI, 4.6-5.5%) to 3.4% (95% CI, 3.0-3.8%). The prevalence of chronic hepatitis C was approximately 0.3% in 2016-2017. The prevalence of NAFLD and ALD increase among Korean adults. Our results suggest potential targets for interventions to reduce the future burden of CLD.

The combination therapy of Peginterferonα and entecavir for HBeAg-positive chronic hepatitis B with high HCC risk

The population of HBV infection with family history of hepatocellular carcinoma (HCC) is the high risk group for the development of HCC. The aim of this study was to evaluate the effect of the de novo combination therapy including pegylated-interferon α-2a (PEG-IFNα-2a) and entecavir (ETV) in this high risk population. The study recruited 58 Hepatitis B e Antigen (HBeAg)-Positive CHB patients patients with HBV-DNA > 10⁷ IU/mL, genotype B or C and HCC family history and were treated for 48 weeks. Patients without HBeAg loss at the 48th week were 40 patients and extended the combination therapy to 96 weeks. All patients were followed up to 120 weeks. The rate of HBeAg loss and HBsAg loss was 12/40(30.0%) and 2/40(5.0%) at week 120 respectively. When logistic regression analysis was used to identify viables of HBeAg loss, HBV-DNA levels <20 IU/mL at week 48 was found to have a 6.02 fold increased probability (95% CI = 1.17-30.40, P = .03) of HBeAg loss. Patients with HBV-DNA levels <20 IU/mL at week 48 had a high probability of HBeAg loss 8/17(47.1%), HBsAg loss 2/17(11.8%), compared to 4/23(17.4%), 0/23(0%) in patients with HBV-DNA ≥ 20 IU/mL. Combination therapy for 96 weeks was well tolerated. During the combination therapy, low-level viremia during treatment is reversely associated with response. The combination therapy of PEG-IFNα and ETV was suggested to extend to 96 weeks when HBV-DNA was completed suppressed at week 48.

Occult hepatitis B and HIV infection

INTRODUCTION

Occult hepatitis B virus (HBV) infection, so-called occult B infection (OBI), is defined by the recognition of HBV-DNA in the absence of serum hepatitis B surface antigen (HBsAg). The HBV-DNA genome in OBI is fully replication competent and produced in the liver, characteristically with low-level HBV-DNA fluctuations in the bloodstream. The OBI status remains between chronic (HBsAg +) and resolved (anti-HBs +) phases in the natural history of HBV infection.

METHODS

The clinical interest in OBI has increased because of its potential for overt HBV reactivation under immunosuppression as well as for HBV transmission, well established in recipients of blood transfusions and/or organ transplants.

RESULTS

Given the shared transmission routes for HIV and HBV, earlier reports claimed that OBI was more frequent in AIDS patients. By contrast, the current scenario shows that OBI is negligible in the HIV population. One explanation is that HBV immunization and recall vaccination campaigns have been very active in this group. A second and most important reason points to the wide use of antiretroviral regimens that include anti-HBV active agents, that is, tenofovir, lamivudine, and/or emtricitabine. They are recommended either as treatment for all HIV carriers or as pre-exposure prophylaxis for uninfected individuals at risk. The consequences are that HBV reactivations associated with HIV-related immunodeficiency have become very rare. Furthermore, HBV suppression with these antivirals has markedly reduced the likelihood of transmission from OBI carriers and/or acquisition by uninfected exposed individuals.

CONCLUSION

Enthusiasm unabated, however, new tenofovir-sparing antiretroviral regimens are becoming popular and might account for a resurgence of OBI in the HIV setting.

The medical impact of hepatitis D virus infection in Uzbekistan

BACKGROUND & AIMS

The hepatitis B virus (HBV) is endemic in Uzbekistan but the medical impact of infection with the HBV-dependent hepatitis D virus (HDV) is unknown in the Country. An Hepatology Center was recently established at the Institute of Virology in Tashkent, which has set up a database enlisting patients with chronic viral liver disorders from all over Uzbekistan; it provides an observatory on the current scenario of viral hepatitis in the Country.

METHODS

The prevalence of HBV monoinfection, hepatitis C virus (HCV) infection and HDV superinfection on hepatitis B surface antigen (HBsAg)-positive cirrhosis was determined in 6589 patients with viral cirrhosis collected in the last 3 years.

RESULTS

Of 1089, 1150 and 1455 carriers of the HBsAg with cirrhosis recruited in 2016, 2017 and 2018, 834 (76.5%), 926 (80.5%) and 1224 (84%) respectively, had antibody to the HDV. In 2016, 2017 and 2018, the prevalence of HDV infection has been 41%, 45% and 49.1% respectively, largely exceeding the prevalence of HBV monoinfection (12.5%, 11% and 9.3% respectively) and surpassing the prevalence of HCV in 2017 and 2018 (44% and 41.5% respectively). The median age of the patients with HDV cirrhosis was 39 years, distinctly lower than that of HBV and HCV patients (46 and 55).

CONCLUSIONS

Superinfection with the HDV is present in over 80% of the HBsAg-positive cirrhosis in Uzbekistan. The HDV appears to be the major cause of advanced viral liver disease and of juvenile cirrhosis in the Country.

Help-Seeking Experiences of Hepatitis B Patients in Transnational Medical Care: The Solution to Health Inequality Is Social Mobility

This paper tracked hepatitis B patients from Medan, Indonesia to Penang, Malaysia under transnational medical care and has an understanding of their medical history and socioeconomic status. The condition of these patients improved as a result of good compliance with medical treatment, including lifestyle adjustment and regular medication. Under the influence of the marketization of healthcare, transnational medical patients in the social structure, based on their economic ability and socioeconomic status, may be expected to experience health inequalities. People with unhealthy medical distribution and weak socioeconomic status are easily prone to diseases due to environmental and social conditions; it is easier for such patients to delay or give up their medical treatment. After continuous tracking and increasing patient exposure to medical knowledge and self-care management opportunities, increasing awareness, screening, care, and treatment, the transmission of hepatitis B can be reduced to enable them to gain upward mobility by their capacities and thus improve their health. Social mobility is deemed the main approach to reduce social inequality. There have been limited medical clinical observations and tracking confirming this theory. This paper, which uses medical observation, confirmed that social mobility is considered as the principal key to reducing inequalities in health.

HCV and HBV prevalence based on home blood self-sampling and screening history in the general population in 2016: contribution to the new French screening strategy

Background

The advent of effective direct-acting antivirals (DAAs), has prompted an assessment of the French Hepatitis C virus (HCV) screening strategy, which historically targeted high-risk groups. One of the options put forward is the implementation of combined (i.e., simultaneous) HCV, Hepatitis B virus (HBV) and HIV screening for all adults at least once during their lifetime (“universal combined screening”). However, recent national survey-based data are lacking to guide decision-making regarding which new strategy to implement. Accordingly, we aimed to provide updated data for both chronic hepatitis C (CHC) and B (CHB) prevalence and for HCV and HBV screening history, using data from the BaroTest and 2016 Health Barometer (2016-HB) studies, respectively.

Methods

2016-HB was a national cross-sectional phone based health survey conducted in 2016 among 20,032 randomly selected individuals from the general population in mainland France. BaroTest was a virological sub-study nested in 2016-HB. Data collected for BaroTest were based on home blood self-sampling on dried blood spots (DBS).

Results

From 6945 analyzed DBS, chronic hepatitis C (CHC) and B (CHB) prevalence was estimated at 0.30% (95% Confidence Interval (CI): 0.13-0.70) and 0.30% (95% CI: 0.13-0.70), respectively. The proportion of individuals aware of their status was estimated at 80.6% (95% CI: 44.2-95.6) for CHC and 17.5% (95% CI: 4.9-46.4) for CHB. Universal combined screening would involve testing between 32.6 and 85.3% of 15-75 year olds according to whether we consider only individuals not previously tested for any of the three viruses, or also those already tested for one or two of the viruses.

Conclusions

Our data are essential to guide decision-making regarding which new HCV screening recommendation to implement in France. They also highlight that efforts are still needed to achieve the WHO’s targets for eliminating these diseases. Home blood self-sampling may prove to be a useful tool for screening and epidemiological studies.

Surveillance-Based Estimate of the Prevalence of Chronic Hepatitis B Virus Infection, New York City, 2016

OBJECTIVES

Chronic hepatitis B virus (HBV) infection is a lifelong infection that can cause serious liver damage and liver cancer. The last surveillance-based prevalence estimate of chronic HBV infection in New York City was 1.2% in 2008; however, it did not account for persons with undiagnosed infection. The objective of this study was to calculate the prevalence of chronic HBV infection, including undiagnosed infection, for 2016 by using surveillance data and literature-based information.

METHODS

We calculated the number of persons with diagnosed chronic HBV infection (2000-2016) who were alive and living in New York City in 2016 by using routine surveillance data. We estimated the percentage of persons with undiagnosed chronic HBV infection by using birth region-specific percentages from the literature, weighted by the proportion of the New York City population with diagnosed chronic HBV infection from the same birth region. We identified minimum, maximum, and most likely values for the percentage with undiagnosed chronic HBV infection to generate 95% certainty limits (CLs) of the prevalence estimate.

RESULTS

The prevalence of chronic HBV infection in 2016, including undiagnosed infection, in New York City was 2.7% (95% CL, 2.2%-3.6%), representing approximately 230 000 persons. The prevalence of diagnosed chronic HBV infection was 1.5%. The estimated prevalence among non-US-born residents was 6.9% (95% CL, 5.4%-8.9%).

CONCLUSIONS

The current burden of chronic HBV infection in New York City, especially for non-US-born residents, is substantial. A renewed focus and dedication of resources is required to increase the number of new diagnoses and improve provider capacity to care for the large number of persons with chronic HBV infection.

Stigma among healthcare workers towards hepatitis B infection in Bangalore, India: a qualitative study

BACKGROUND

With about 50 million people infected with hepatitis B (HBV) in India the burden of disease is high. Stigma has been identified to have a major negative impact on screening, diagnosis and treatment of hepatitis B patients. The aim of this study was to assess the stigma in nurses and physicians in Bangalore, India; studies on stigma in HBV have only been published outside of India.

METHODS

Semi-structured in-depth-interviews were conducted in the period of March 20th and April 16th 2018 to study stigma and other problems in the care of hepatitis B patients. Stigma was pragmatically defined as a mark of disgrace associated with having a hepatitis B infection. Thirty physicians and nurses in different clinics and hospitals across the city of Bangalore were selected by purposeful sampling and snowball effect until theoretical saturation was reached.

RESULTS

The following themes were identified during the interviews: feelings when treating a patient; pregnancy and marriage; confidentiality; morality; improvement in care and the difference with HIV. The most stigma was discovered in the theme morality. The majority of our participants mentioned lack of awareness as biggest obstacle in health care of hepatitis B patients.

CONCLUSIONS

This is the first qualitative study in India exploring hepatitis B stigma among health care workers. Stigma was found in certain themes, such as morality. Though, no unwillingness to treat was found. There was a general lack of awareness amongst patients according to our participants and could jeopardize proper treatment. These results will further help in developing strategies to tackle hepatitis B in India.

MicroRNA-3163 targets ADAM-17 and enhances the sensitivity of hepatocellular carcinoma cells to molecular targeted agents

Molecular targeted agents, such as sorafenib, remain the only choice of an antitumor drug for the treatment of advanced hepatocellular carcinoma (HCC). The Notch signaling pathway plays central roles in regulating the cellular injury/stress response, anti-apoptosis, or epithelial–mesenchymal transition process in HCC cells, and is a promising target for enhancing the sensitivity of HCC cells to antitumor agents. The ADAM metalloprotease domain-17 (ADAM-17) mediates the cleavage and activation of Notch protein. In the present study, microRNA-3163 (miR-3163), which binds to the 3′-untranslated region of ADAM-17, was screened using online methods. miRDB and pre-miR-3163 sequences were prepared into lentivirus particles to infect HCC cells. miR-3163 targeted ADAM-17 and inhibited the activation of the Notch signaling pathway. Infection of HCC cells with miR-3163 enhanced their sensitivity to molecular targeted agents, such as sorafenib. Therefore, miR-3163 may contribute to the development of more effective strategies for the treatment of advanced HCC.

State of viral hepatitis care in 16 countries of Central and Eastern European Region

OBJECTIVES

Survey was conducted to assess state of viral hepatitis care in Central and Eastern Europe (CEE).

METHODS

Representatives of 16 CEE countries completed on-line survey in April-May 2017 that collected information on basic epidemiology and availability of key services for HCV and HBV infections. Sources of information provided ranged from national surveillance data to expert opinion.

RESULTS

The burden of viral hepatitis varied between countries, ranging from 6,500 to 2 million for HCV and from 10,000 to 3 million for HBV. Access to routine HCV RNA testing and genotyping was reported by 11 and 9 countries, respectively. HCV resistance testing was available in 7 countries. Direct acting antivirals (DAAs) were available in 13 countries, most frequently Sofosbuvir and Ledipasvir/Sofosbuvir (12 countries apiece) and Ombitasvir/Paritaprevir/Dasabuvir (9 countries). HBV DNA testing and HBV genotyping were routinely available in 10 and 7 countries, respectively. Eleven countries reported available treatment with Tenofovir.

CONCLUSIONS

There are gaps in viral hepatitis care in CEE. Despite the availability of registered modern drugs for HCV and HBV, the access to treatment is limited. Ensuring quality health care is essential to reduce the epidemic and achieve the WHO's goal of eliminating viral hepatitis as a major public health challenge.

First line nucleos(t)ide analog monotherapy is more cost-effective than combination strategies in hepatitis B e antigen-positive chronic hepatitis B patients in China

BACKGROUND

Nucleos(t)ide analog (NA) in combination with peginterferon (PegIFN) therapy in patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) shows better effectiveness than NA monotherapy in hepatitis B surface antigen loss, termed "functional cure," based on previous published studies. However, it is not known which strategy is more cost-effective on functional cure. The aim of this study was to analyze the cost-effectiveness of first-line monotherapies and combination strategies in HBeAg-positive CHB patients in China from a social perspective.

METHODS

A Markov model was developed with functional cure and other five states including CHB, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, and death to assess the cost-effectiveness of seven representative treatment strategies. Entecavir (ETV) monotherapy and tenofovir disoproxil fumarate (TDF) monotherapy served as comparators, respectively.

RESULTS

In the two base-case analysis, compared with ETV, ETV generated the highest costs with $44,210 and the highest quality-adjusted life-years (QALYs) with 16.78 years. Compared with TDF, treating CHB patients with ETV and NA - PegIFN strategies increased costs by $7639 and $6129, respectively, gaining incremental QALYs by 2.20 years and 1.66 years, respectively. The incremental cost-effectiveness ratios were $3472/QALY and $3692/QALY, respectively, which were less than one-time gross domestic product per capita. One-way sensitivity analysis and probabilistic sensitivity analyses showed the robustness of the results.

CONCLUSION

Among seven treatment strategies, first-line NA monotherapy may be more cost-effective than combination strategies in HBeAg-positive CHB patients in China.

HCV point-of-care screening programme and treatment options for people who use drugs in a metropolitan area of Southern Italy

BACKGROUND AND AIMS

People who use drugs (PWUD) represent an active reservoir of HCV infection. The prevalence of chronic HCV infection in PWUD in Italy remains unknown because of the lack of systematic screening. Thanks to direct-acting antiviral agents (DAAs), hepatitis C can now be cured in most patients. Thus, the next challenge is to provide linkage-to-care for these patients.

METHODS

In this scenario, we conducted a screening programme in PWUD attending seven Addiction Centers in Southern Italy, as well as a treatment programme in the Liver Unit of the University Hospital of Salerno. We used the OraQuick HCV antibody test to screen the PWUD (from 1 April to 30 September 2018).

RESULTS

593 subjects were consecutively enrolled in the programme; 250 (41.8%) were HCV-Ab-positive. 143 (24.1%) were aware of their infection and had been HCV-RNA-tested: 83 were positive and 60 negative. The remaining 107 subjects (18.1%) had never previously been tested and were unaware of their infection. A total of 160 (26.9%) HCV RNA-positive patients were found and offered antiviral therapy with DAAs. The sustained virological response rate was 98.5% and no adverse events were recorded. Two patients voluntarily discontinued treatment. No reinfections have been recorded to date.

CONCLUSIONS

The prevalence of HCV-Ab positivity was high in the PWUDs enrolled in this study, and almost half the patients were unaware of being HCV-positive. The linkage-to-care provided was safe and effective, and no case of reinfection was recorded.

Clinical utility of HBV surface antigen quantification in HBV e antigen-negative chronic HBV infection

Chronic hepatitis B virus (HBV) infection is a serious problem owing to its worldwide distribution and potential adverse sequelae that include cirrhosis and/or hepatocellular carcinoma. Current antiviral therapies have much improved outcomes, but few patients achieve the ultimate goal of hepatitis B surface antigen (HBsAg) loss (functional cure). As hepatitis B e antigen (HBeAg)-negative chronic HBV infection is the final phase prior to HBsAg loss, the management of patients in this phase together with quantification of HBsAg has attracted increasing clinical and research interest. This Review integrates the findings from research in HBsAg kinetics and discusses how they might inform our understanding and management of HBeAg-negative chronic HBV infection. Studies have shown that HBsAg levels are highly predictive of the presence of inactive HBV infection and that serial changes in HBsAg levels might predict HBsAg loss within 1-3 years. Data also suggest that quantitative HBsAg monitoring is important during hepatitis flare and antiviral therapy, especially in the timing of the decision to stop therapy and to start off-therapy retreatment. These findings have shed new light on the natural course of HBV infection and might lead to optimization of the management of HBeAg-negative chronic HBV infection and contribute to the paradigm shift from indefinite to finite therapy for patients with HBV infection.

The impact of HBV flare on the outcome of HBV-related decompensated cirrhosis patients with bacterial infection

BACKGROUND

Hepatitis B virus (HBV) flare can occur in HBV patients either naïve or have interruption to treatment. Bacterial infection (BI) is a common complication of cirrhosis with potential severe outcomes. We aimed to assess the impact of HBV flare on the outcome of patients with HBV-related decompensated cirrhosis and BI.

METHODS

This was a retrospective study from 2 tertiary academic hospitals in Shanghai, China of HBV patients admitted with or developed BI during admission. The characteristics of BI, prevalence of HBV flare, its impact on organ failure, acute-on-chronic liver failure (ACLF) and 90-day survival were evaluated.

RESULTS

A total of 360 hospitalized patients (median age: 50 years, male: 79%, BI: at admission: 58.6%; during admission: 41.4%) were included. All patients including those with HBV flare (21%) received antiviral therapy after admission. Patients with HBV flare and BI had significantly higher percentage of liver (93.3% vs 48.8%), coagulation (64.0% vs 39.6%), cerebral (40.0% vs 21.8%) (all P < 0.01), and kidney failure (38.7% vs 26.3%, P < 0.05) compared to BI alone, associated with a higher risk of developing ACLF with a subdistribution hazard ratio (sHR) of 2.23 (95% confidence interval [CI]: 1.68-2.96). Multivariate analysis showed that ACLF development was the strongest risk factor for 90-day mortality (sHR, 95%CI: 7.36, 4.12-13.16).

CONCLUSIONS

In HBV-related decompensated cirrhosis patients admitted with BI, HBV flare increased the risk of additional organ failures and ACLF, raising the risk of 90-day mortality by seven-fold. Optimization of HBV treatment in these patients should minimize the risk of HBV flare with improved outcomes.

A Potential Functional Cure in Chinese HBeAg-negative Chronic Hepatitis B Patients Treated with Peg-interferon Alpha-2a

Background and Aims: Data are limited on the use of pegylated-interferon alpha-2a (peg-IFNα) in Chinese patients with chronic hepatitis B virus (HBV) infection (CHB). We evaluated the effectiveness and safety of peg-IFNα in Chinese patients with hepatitis B envelope antigen-negative CHB in routine clinical practice. Methods: In this prospective, multicenter, observational, non-interventional cohort study, patients were assessed for up to 1 year after peg-IFNα treatment cessation. Treating physicians established the dosing and treatment duration according to Chinese clinical practice. Effectiveness of peg-IFNα treatment was measured by the percentage of: patients with HBV DNA <2000 IU/mL and loss of hepatitis B surface antigen (commonly known as HBsAg); HBV DNA level at end of treatment (EOT), and 6 months and 1 year posttreatment; and time course change in quantitative HBV DNA and HBsAg. Results: At EOT, 6 months posttreatment, and 1 year posttreatment, the percentage of patients with HBV DNA <2000 IU/mL was 90.0%, 81.8%, and 82.2%, and that of patients with HBsAg loss was 6.5%, 9.4%, and 9.5%, respectively. The HBV DNA level decreased from 5.61 log IU/mL at baseline to 2.48 log IU/mL at EOT and 2.67 log IU/mL at 1 year posttreatment. The HBsAg level decreased from 3.08 log IU/mL at baseline to 2.24 log IU/mL at EOT and 2.10 log IU/mL at 1 year posttreatment. The incidence of adverse events was 52.0%. Conclusions: Peg-IFNα has the potential to provide functional cure (HBsAg loss) for CHB and is well tolerated in hepatitis B envelope antigen-negative CHB patients in routine clinical practice in China. Clinical Trial Registration: ClinicalTrials.gov (NCT01730508).

Quantitative HBsAg levels do not identify hepatic fibrosis in HBeAg-negative chronic hepatitis B patients

BACKGROUND/AIMS

Quantitative serum hepatitis B surface antigen (qHBsAg) has been evaluated in limited patient groups as a marker of histological fibrosis. The accurate identification of inactive chronic hepatitis B virus (HBV) carriers from those with active carriers is difficult because of wide and frequent HBV DNA fluctuations. We aimed to assess the utility of qHBsAg in distinguishing histologically significant fibrosis in untreated HBeAg-negative chronic HBV patients.

PATIENTS AND METHODS

qHBsAg levels were measured at baseline as single-point quantification and correlated with virologic and biochemical profiles of consecutive carriers (median, 29; range, 12-110 months). HBeAg-negative patients (n = 75) with HBV DNA <2000 (n = 5), 2000-20,000 (n = 16) and >20,000 IU/mL (n = 54) were included and all had liver biopsy. A qHBsAg cutoff point of 1000 IU/mL was assessed to demonstrate whether it better delineated patients with non-significant histology (F0-1, inflammatory grade A0-1).

RESULTS

Mean age of the patients was 39.4 ± 11.4 years and 58 (77.3%) were male. Patients with qHBsAg levels >1000 IU/mL were more likely to be males (84.5%, P = 0.006) or with elevated AST (68.4%, P = 0.0002) and ALT levels (72.4%, P < 0.0001), higher HBV DNA (log₁₀ 6.4 ± 1.4, P < 0.0001) and those with F2-4 fibrosis (48.3%, P = 0.028). Serum log₁₀ qHBsAg were significantly lower in patients with HBV DNA <2000 (2.80 ± 1.47) and HBV DNA 2000-20,000 (2.71 ± 0.83) vs. >20,000 IU/mL (3.89 ± 0.61, P < 0.0001). Overall, qHBsAg were not different in patients with F0-1 (3.44 ± 0.91) and F2-4 fibrosis (3.74 ± 0.85, P = 0.161). Serum qHBsAg were higher in patients with significant (A2-3) inflammation (3.85 ± 0.72) compared to A0-1 (3.38 ± 0.95; P = 0.018). Serum qHBsAg demonstrated poor accuracy (AUROC, 0.61, P = 0.111) in identification of F2-4 fibrosis.

CONCLUSION

Serum qHBsAg levels do not help differentiate between those with HBV DNA <2000 or 2000 - 20,000 IU/mL or distinguish patients with significant fibrosis. Moreover, more than half of the patients with non-significant fibrosis have a qHBsAg level greater than 1000 IU/mL.

Toward a Functional Cure for Hepatitis B: The Rationale and Challenges for Therapeutic Targeting of the B Cell Immune Response

The central role of the cellular immune response in the control and clearance of the hepatitis B virus (HBV) infection has been well-established. The contribution of humoral immunity, including B cell and antibody responses against HBV, has been investigated for a long time but has attracted increasing attention again in recent years. The anti-HBs antibody was first recognized as a marker of protective immunity after the acute resolution of the HBV infection (or vaccination) and is now defined as a biomarker for the functional cure of chronic hepatitis B (CHB). In this way, therapies targeting HBV-specific B cells and the induction of an anti-HBs antibody response are essential elements of a rational strategy to terminate chronic HBV infection. However, a high load of HBsAg in the blood, which has been proposed to induce antigen-specific immune tolerance, represents a major obstacle to curing CHB. Long-term antiviral treatment by nucleoside analogs, by targeting viral translation by siRNA, by inhibiting HBsAg release via nucleic acid polymers, or by neutralizing HBsAg via specific antibodies could potentially reduce the HBsAg load in CHB patients. A combined strategy including a reduction of the HBsAg load via the above treatments and the therapeutic targeting of B cells by vaccination may induce the appearance of anti-HBs antibodies and lead to a functional cure of CHB.

Enhancing the value of women's reproductive rights through community based interventions in upper Egypt governorates: a randomized interventional study

BACKGROUND

In 2012, the WHO described the quality of health care as the route to equity and dignity for women and children.

AIM OF THE WORK

To provide community based support and empowerment to women in childbearing period to seek optimal prenatal, natal and postnatal healthcare. Achieving this is anticipated to decrease maternal morbidity and mortality in Egypt.

SUBJECTS AND METHODS

An interventional study was conducted among women in childbearing period in the poorest two governorates of Upper Egypt. The study passed through three stages over three and a half years; pre-interventional assessment of awareness (n = 1000), educational interventions targeting the health providers and all women in childbearing period in their communities (n = 20,494), and post-intervention evaluation of change in awareness of their rights for prenatal, natal and postnatal care (no = 1150).

RESULTS

The studied indicators relating to receiving care in pregnancy, labor, and puerperium have changed dramatically as a result of the study interventions. Results of the study showed that before interventions, the surveyed women had inaccurate knowledge regarding most of the items related to their rights. The percentages of women aware of their right to have pregnancy card increased and those who possessed a pregnancy card were doubled with a significant percent change of more than 25%. Some indicators showed more than 75% improvement, including; percent of surveyed women who knew that it's their right to follow up their pregnancy and to deliver with a specialized doctor, a trained nurse or at an equipped health facility, and those who knew their right to have at least two home preparations necessary for safe delivery at home.

CONCLUSION AND RECOMMENDATIONS

More work is needed in order to achieve the targeted reduction of maternal mortality. This could be achieved by ensuring accessible and high quality care provided by the governmental health facilities together with increasing the awareness of women regarding their rights in receiving such care.

Epidemiology of chronic hepatitis B and C in Victoria, Australia: insights and impacts from enhanced surveillance

OBJECTIVE

To assess the impact of an enhanced viral hepatitis surveillance program on data completeness and on epidemiological assessment of affected populations.

METHODS

Notified cases of non-acute hepatitis B and C were analysed to determine demographic characteristics and risk factors during the period prior to July 2015-June 2016, and during enhanced surveillance of the period July 2016-June 2017, during which time doctors were contacted for information about new diagnoses.

RESULTS

During the enhanced period, completeness for country of birth and Indigenous status doubled for both hepatitis B and hepatitis C, from 18-37% to 48-65%. The incidence ratio of hepatitis C among Aboriginal and Torres Strait Islander people increased from eight-fold to 11.4-fold, and the proportion of hepatitis B cases reported as born in China and Vietnam relative to other countries increased. New data fields identified that 12% of hepatitis C diagnoses occurred in a correctional facility, and 2% of hepatitis B cases were healthcare workers.

CONCLUSIONS

Improved data completeness highlighted the underlying epidemiology of chronic viral hepatitis, demonstrating the increased burden of infection among specific priority populations. Implications for public health: Enhanced surveillance provides greater insight into the epidemiology of chronic viral hepatitis, identifying groups at risk and opportunities for public health action.

SREBP-1 inhibitor Betulin enhances the antitumor effect of Sorafenib on hepatocellular carcinoma via restricting cellular glycolytic activity

Lipid metabolism that correlates tightly to the glucose metabolic regulation in malignant cells includes hepatocellular carcinoma (HCC) cells. The transcription factor Sterol Regulatory Element Binding Protein 1 (SREBP-1), a regulator of fatty acid synthesis, has been shown to pivotally regulate the proliferation and metastasis of HCC cells. However, the intrinsic mechanism by which SREBP-1 regulates the survival of HCC cells remains unclear. In this study, among HCC patients who had dismal responses to Sorafenib, a high SREBP-1 level was found in the tumors and correlated to poor survival. This observation suggested the negative role of SREBP-1 in clinical HCC prognosis. Our mechanistical studies reveal that the inhibition of SREBP-1 via its inhibitor Betulin suppresses cellular glucose metabolism. In addition to the reduced glycolytic activity, a thwarted metastatic potential was observed in HCC cells upon Betulin administration. Moreover, our data show that SREBP-1 inhibition facilitated the antitumor effects of Sorafenib on HCC cells and xenograft tumors.

Knowledge, awareness, attitude, and practice of health-care professionals toward hepatitis B disease and vaccination in Saudi Arabia

Objectives: Health-care professionals (HCPs) are at very high risk for accidental exposure to hepatitis B virus (HBV) from infected patients; as such, this study aimed to investigate the knowledge, awareness, attitude, and practice of HCPs toward hepatitis B vaccination.Methods: We conducted a cross-sectional study with a pre-tested, validated questionnaire in seven major cities in Saudi Arabia from January to April 2015. The questionnaire consisted of four sections: demographics, knowledge, awareness of hepatitis B infection, and attitude of HCPs toward HBV. We analyzed the data collected from study participants using SAS® V9.2.Results: Approximately 16.5% of participants reported that they had not received the hepatitis B vaccine; however, the majority of participants believed that hepatitis B is common (73.2%) and that vaccination is an effective strategy to reduce disease incidence (75%). Availability of the vaccine was a major barrier to vaccination (48.7%), together with safety concerns surrounding the vaccine (37%).Approximately 31.2% of non-vaccinated participants believed the hepatitis B vaccine is not safe, while only 8% possessed this belief in the vaccinated group. Additionally, 36.4% of non-vaccinated participants were unsure of the effectiveness of the vaccine, compared to 24.3% in the vaccinated group. Inability to afford the vaccine was reported by 18.2% of the non-vaccinated group compared to only 4% of vaccinated participants.Conclusion: There is notable hepatitis B vaccination coverage among HCPs, but observed levels are below global standards. We believe the hurdles preventing non-vaccinated HCPs from being immunized must be addressed.

Pharmacokinetics, Safety and Tolerability of JNJ-56136379, a Novel Hepatitis B Virus Capsid Assembly Modulator, in Healthy Subjects

INTRODUCTION

Hepatitis B viral capsid assembly is an attractive target for new antiviral treatments. JNJ-56136379 (JNJ-6379) is a potent capsid assembly modulator in vitro with a dual mode of action. In Part 1 of this first-in-human study in healthy adults, the pharmacokinetics (PK), safety and tolerability of JNJ-6379 were evaluated following single ascending and multiple oral doses.

METHODS

This was a double-blind, randomized, placebo-controlled study in 30 healthy adults. Eighteen subjects were randomized to receive single doses of JNJ-6379 (25 to 600 mg) or placebo. Twelve subjects were randomized to receive 150 mg JNJ-6379 or placebo twice daily for 2 days, followed by 100 mg JNJ-6379 or placebo daily for 10 days.

RESULTS

The maximum observed plasma concentration and the area under the curve increased dose proportionally from 25 to 300 mg JNJ-6379. Following multiple dosing, steady-state conditions were achieved on day 8. Steady-state clearance was similar following single and multiple dosing, suggesting time-linear PK. All adverse events (AEs) reported were mild to moderate in severity. There were no serious AEs or dose-limiting toxicities and no apparent relationship to dose for any AE.

CONCLUSION

JNJ-6379 was well tolerated in this study. Based on the safety profile and plasma exposures of JNJ-6379 in healthy subjects, a dosing regimen was selected for Part 2 of this study in patients with chronic hepatitis B. This is anticipated to achieve trough plasma exposures of JNJ-6379 at steady state of more than three times the 90% effective concentration of viral replication determined in vitro.

TRIAL REGISTRATION

Clinicaltrials.gov identifier, NCT02662712.

FUNDING

Janssen Pharmaceutica.

Persistence of HBsAg-specific antibodies and immune memory two to three decades after hepatitis B vaccination in adults

The duration of protection after hepatitis B vaccination is not exactly known. This phase IV study evaluated antibody persistence and immune memory 20-30 years after adult immunization with recombinant hepatitis B vaccine (HBsAg vaccine, Engerix-B) in routine clinical practice. Men and women 40-60 years old, with documented evidence of vaccination with three or four HBsAg vaccine doses 20-30 years earlier and without subsequent booster, were enrolled and received HBsAg vaccine as challenge dose. HBsAg-specific antibodies (anti-HBs) and frequencies of HBsAg-specific circulating memory B cells and CD4+ T cells expressing combinations of activation markers (CD40L, IL2, IFNγ, TNFα) were measured prechallenge, 7 and 30 days postchallenge. Of 101 participants in the according-to-protocol cohort for immunogenicity, 90.1% had anti-HBs concentrations ≥ 10 mIU/mL prechallenge administration; 84.2% and 100% mounted an anamnestic response 7 and 30 days postchallenge, respectively. HBsAg-specific memory B and CD4+ T cells expressing at least two activation markers were low prechallenge and increased markedly postchallenge. These results suggest sustained immune memory and long-term protection 20-30 years after a complete primary HBsAg vaccination course during adulthood, in line with current recommendations that a booster is not needed in fully vaccinated immunocompetent adults.